Functional matrix metalloproteinase (MMP)-9 genetic variants modify the effects of hemodialysis on circulating MMP-9 levels

Background: Altered levels of matrix metalloproteinases (MMPs) and their inhibitors, the tissue inhibitors of metalloproteinases (TIMPs), are involved in cardiovascular alterations associated with end stage kidney disease (ESKD). Genetic polymorphisms in MMP-9 gene affect MMP-9 levels. We examined how MMP-9 polymorphisms and haplotypes affect the changes in plasma MMP-9 and TIMP-1 levels found in patients with ESKD undergoing hemodialysis. Methods: We studied 94 ESKD patients undergoing hemodialysis for at least 3 months. MMP-9 and TIMP-1 were measured by ELISA in plasma from blood samples collected before and after a session of hemodialysis. Genotypes for three MMP-9 polymorphisms (C-1562T, rs3918242; -90 (CA)(14-24), rs2234681; and Q279R, rs17576) were determined by Taqman (R) Allele Discrimination Assay and real-time polymerase chain reaction. Haplotype frequencies were determined with the software program PHASE 2.1. Results: Hemodialysis increased MMP-9 and TIMP-1 levels (P<0.05). Genotypes had no effects on baseline MMP-9 and TIMP-1 levels (P>0.05). Hemodialysis increased MMP-9 and TIMP-1 levels in subjects with the CC (but not CT or TT) genotype for the C-1562T polymorphism (P<0.05), and increased MMP-9 levels in subjects with the QQ (but not QR or RR) genotype for the Q279R polymorphism (P<0.05), whereas the CA(n)(14-24) polymorphism had no major effects. While MMP-9 haplotypes had no effects on baseline MMP-9 levels (P>0.05), hemodialysis increased MMP-9 levels and MMP-9/TIMP-1 ratios in subjects carrying the CLQ haplotype (P = 0.0012 and P = 0.0045, respectively). Conclusion: ESKD patients with the QQ genotype for the Q279R polymorphism or with the CLQ haplotype are exposed to more severe increases in MMP-9 levels after hemodialysis. Such patients may benefit from the use of MMP inhibitors. (C) 2012 Elsevier B.V. All rights reserved.

Vitamin D receptor polymorphisms in hypertensive disorders of pregnancy

Hypertension is the most common medical disorder in pregnancy, and a leading cause of maternal and neonatal morbidity and mortality. Vitamin D endocrine system has important influence on immune modulation and endothelial function, which play a role in preeclampsia (PE) and gestational hypertension (GH). Vitamin D receptor (VDR) is present in a large variety of cell types, including placental cells. We examined whether there is an association between VDR polymorphisms (FokI, ApaI and BsmI) with PE or with GH. Restriction fragment length polymorphism techniques were used to genotype 529 pregnant (154 with GH, 162 with PE, and 213 healthy pregnant-HP). VDR haplotype frequencies were inferred using the PHASE 2.1 program. We found similar genotype distributions for the three VDR polymorphisms in both PE and GH groups compared with the HP group (all P > 0.05). In parallel with these findings, the VDR haplotype frequency distribution was similar in both PE and GH groups compared with the HP group (all P > 0.05). Our results showing no significant association between VDR polymorphisms or haplotypes with PE or GH suggest that genetic variations in VDR do not predispose to hypertensive disorders of pregnancy.

Outsourcing Operations in Project Management Offices: The Reality of Brazilian Companies

The purpose of this study is to explore the mechanisms that influence decisions regarding outsourcing competencies in the operation of project management offices (PMOs). The exploratory research described here involves the use of a web-based survey for enterprises in Brazil. In 78 of the survey's valid cases, the PMO is operated using the organization's internal resources. A possible conclusion is that the PMO is unlikely to positively relate to the culture of external services used by the organization and to use outsourcing to operate the PMO.

Food choices and practices during pregnancy of immigrant and Aboriginal women in Canada: a study protocol

Abstract Background Facilitating the provision of appropriate health care for immigrant and Aboriginal populations in Canada is critical for maximizing health potential and well-being. Numerous reports describe heightened risks of poor maternal and birth outcomes for immigrant and Aboriginal women. Many of these outcomes may relate to food consumption/practices and thus may be obviated through provision of resources which suit the women's ethnocultural preferences. This project aims to understand ethnocultural food and health practices of Aboriginal and immigrant women, and how these intersect with respect to the legacy of Aboriginal colonialism and to the social contexts of cultural adaptation and adjustment of immigrants. The findings will inform the development of visual tools for health promotion by practitioners. Methods/Design This four-phase study employs a case study design allowing for multiple means of data collection and different units of analysis. Phase 1 consists of a scoping review of the literature. Phases 2 and 3 incorporate pictorial representations of food choices (photovoice in Phase 2) with semi-structured photo-elicited interviews (in Phase 3). The findings from Phases 1-3 and consultations with key stakeholders will generate key understandings for Phase 4, the production of culturally appropriate visual tools. For the scoping review, an emerging methodological framework will be utilized in addition to systematic review guidelines. A research librarian will assist with the search strategy and retrieval of literature. For Phases 2 and 3, recruitment of 20-24 women will be facilitated by team member affiliations at perinatal clinics in one of the city's most diverse neighbourhoods. The interviews will reveal culturally normative practices surrounding maternal food choices and consumption, including how women negotiate these practices within their own worldview and experiences. A structured and comprehensive integrated knowledge translation plan has been formulated. Discussion The findings of this study will provide practitioners with an understanding of the cultural differences that affect women's dietary choices during maternity. We expect that the developed resources will be of immediate use within the women's units and will enhance counseling efforts. Wide dissemination of outputs may have a greater long term impact in the primary and secondary prevention of these high risk conditions.

Unidad didáctica "El cartero de Neruda" (Ardiente paciencia) de Antonio Skármeta y la versión cinematográfica "El cartero (y Pablo Neruda)" de Michael Radford

Módulo B del Curso La palabra cinematográfica: Didáctica de las relaciones Literatura y Cine, Curso impartido dentro del Programa de Formación y Perfeccionamiento del Profesorado del Colegio oficial de doctores y licenciados en Filosofía y Letras y en Ciencias de Las Palmas (Islas Canarias). Con Convenio de colaboración con la Consejería de Educación, Universidades, Cultura y Deportes (octubre y diciembre de 2004).

Construção e validação de um sistema para observação do 2 vs 2 no andebol

[ES] El objetivo de este trabajo es presentar una herramienta desarrollada para observar, codificar y analizar el ataque en el balonmano 2 vs 2, analizando la fiabilidad. La herramienta está constituida por un sistema mixto de formato de campo y sistemas de categorías. Se ha utilizado el programa informático Hoisan para observar los partidos con el fin de comprobar la fiabilidad del sistema.

Valutazione del comportamento differito di una trave inflessa realizzata in due fasi

La presente tesi analizza il comportamento differito in una prova di flessione su quattro punti su una trave prefabbricata con getto di soletta integrativa in opera. Sono riportati i risultati della prova di carico e di rottura sulla trave. Le prove sono state eseguite presso il Laboratorio di Prove Strutture (DISTART) dell'Università di Bologna. La trave è composta di due tipi di calcestreuzzo, realizzati in tempi diversi e con proprietà meccaniche diverse. L'obiettivo della campagna sperimentale è studiare l'effetto delle fasi di costruzione sull'evoluzione delle tensioni e delle deformazioni nel tempo e sulla resistenza ultima della trave. Il comportamento sperimentale è stato confrontato con i risultati numerici ottenuti con un modello a fibre in grado di cogliere anche i fenomeni legati al creep.

Azione antiossidante del sulforafane: analisi in cellule cardiache in coltura ed in un modello animale di esercizio fisico

Oxidative stress is considered to be of major relevance for a variety of pathological processes. Thus, it is valuable to identify compounds, which might act as antioxidants, i.e. compounds that antagonize the deleterious action of reactive oxygen species (ROS) on biomolecules. The mode of action of these compounds could be either to scavenge ROS directly or to trigger protective mechanisms inside the cell, thereby resulting in improved defense against ROS. Sulforaphane (SF) (1-isothiocyanato-(4R)-(methylsulfinyl)butane) is a naturally occurring cancer chemopreventive agent found as a precursor glucosinolate in Cruciferous vegetables like broccoli. Although SF is not a direct-acting antioxidant, there is substantial evidence that SF acts indirectly to increase the antioxidant capacity of animal cells and their abilities to cope with oxidative stress. Induction of phase 2 enzymes is one means by which SF enhances the cellular antioxidant capacity. Enzymes induced by SF include Glutathione S-transferases (GST) and NAD[P]H:quinone oxidoreductase (NQO1) which can function as protectors against oxidative stress. To protect themselves from oxidative stress, cells are equipped with reducing buffer systems including the GSH and thioredoxin (Trx) reductase. GSH is an important tripeptide thiol which in addition to being the substrate for GSTs maintains the cellular oxidation– reduction balance and protects cells against free radical species. Aim of the first part of this thesis was to investigate the ability of SF to induce the expression and the activity of different phase 2 and antioxidant enzymes (such as GST, GR, GPx, NQO1, TR, SOD, CAT) in an in vitro model of rat cardiomyocytes, and also to define if SF treatment supprts cells in counteracting oxidative stress induced by H2O2 It is well known that acute exhaustive exercise causes significant reactive oxygen species generation that results in oxidative stress, which can induce negative effects on health and well being. In fact, increased oxidative stress and biomarkers (e.g., protein carbonyls, MDA, and 8- hydroxyguanosine) as well as muscle damage biomarkers (e.g. plasmatic Creatine cinase and Lactate dehydrogenase) have been observed after supramaximal sprint exercises, exhaustive longdistance cycling or running as well as resistance-type exercises, both in trained and untrained humans. Markers of oxidative stress also increase in rodents following exhaustive exercise. Moreover, antioxidant enzyme activities and expressions of antioxidant enzymes are known to increase in response to exhaustive exercise in both animal and human tissues. Aim of this project was to evaluate the effect of SF supplementation in counteracting oxidative stress induced by physical activity through its ability to induce phase 2, and antioxidant enzymes in rat muscle. The results show that SF is a nutraceutical compound able to induce the activity of different phase 2 and antioxidant enzymes in both cardiac muscle and skeletal muscle. Thanks to its actions SF is becoming a promising molecule able to prevent cardiovascular damages induced by oxidative stress and muscle damages induced by acute exhaustive exercise.

Applications of High Speed Configurable Logic Devices in Modern Particle Physics Experiments

Several activities were conducted during my PhD activity. For the NEMO experiment a collaboration between the INFN/University groups of Catania and Bologna led to the development and production of a mixed signal acquisition board for the Nemo Km3 telescope. The research concerned the feasibility study for a different acquisition technique quite far from that adopted in the NEMO Phase 1 telescope. The DAQ board that we realized exploits the LIRA06 front-end chip for the analog acquisition of anodic an dynodic sources of a PMT (Photo-Multiplier Tube). The low-power analog acquisition allows to sample contemporaneously multiple channels of the PMT at different gain factors in order to increase the signal response linearity over a wider dynamic range. Also the auto triggering and self-event-classification features help to improve the acquisition performance and the knowledge on the neutrino event. A fully functional interface towards the first level data concentrator, the Floor Control Module, has been integrated as well on the board, and a specific firmware has been realized to comply with the present communication protocols. This stage of the project foresees the use of an FPGA, a high speed configurable device, to provide the board with a flexible digital logic control core. After the validation of the whole front-end architecture this feature would be probably integrated in a common mixed-signal ASIC (Application Specific Integrated Circuit). The volatile nature of the configuration memory of the FPGA implied the integration of a flash ISP (In System Programming) memory and a smart architecture for a safe remote reconfiguration of it. All the integrated features of the board have been tested. At the Catania laboratory the behavior of the LIRA chip has been investigated in the digital environment of the DAQ board and we succeeded in driving the acquisition with the FPGA. The PMT pulses generated with an arbitrary waveform generator were correctly triggered and acquired by the analog chip, and successively they were digitized by the on board ADC under the supervision of the FPGA. For the communication towards the data concentrator a test bench has been realized in Bologna where, thanks to a lending of the Roma University and INFN, a full readout chain equivalent to that present in the NEMO phase-1 was installed. These tests showed a good behavior of the digital electronic that was able to receive and to execute command imparted by the PC console and to answer back with a reply. The remotely configurable logic behaved well too and demonstrated, at least in principle, the validity of this technique. A new prototype board is now under development at the Catania laboratory as an evolution of the one described above. This board is going to be deployed within the NEMO Phase-2 tower in one of its floors dedicated to new front-end proposals. This board will integrate a new analog acquisition chip called SAS (Smart Auto-triggering Sampler) introducing thus a new analog front-end but inheriting most of the digital logic present in the current DAQ board discussed in this thesis. For what concern the activity on high-resolution vertex detectors, I worked within the SLIM5 collaboration for the characterization of a MAPS (Monolithic Active Pixel Sensor) device called APSEL-4D. The mentioned chip is a matrix of 4096 active pixel sensors with deep N-well implantations meant for charge collection and to shield the analog electronics from digital noise. The chip integrates the full-custom sensors matrix and the sparsifification/readout logic realized with standard-cells in STM CMOS technology 130 nm. For the chip characterization a test-beam has been set up on the 12 GeV PS (Proton Synchrotron) line facility at CERN of Geneva (CH). The collaboration prepared a silicon strip telescope and a DAQ system (hardware and software) for data acquisition and control of the telescope that allowed to store about 90 million events in 7 equivalent days of live-time of the beam. My activities concerned basically the realization of a firmware interface towards and from the MAPS chip in order to integrate it on the general DAQ system. Thereafter I worked on the DAQ software to implement on it a proper Slow Control interface of the APSEL4D. Several APSEL4D chips with different thinning have been tested during the test beam. Those with 100 and 300 um presented an overall efficiency of about 90% imparting a threshold of 450 electrons. The test-beam allowed to estimate also the resolution of the pixel sensor providing good results consistent with the pitch/sqrt(12) formula. The MAPS intrinsic resolution has been extracted from the width of the residual plot taking into account the multiple scattering effect.

Identifizierung von T-Zell-erkannten Nierenzellkarzinom-Antigenen

Eine Voraussetzung für die Entwicklung neuer immunmodulatorischer Therapieverfahren ist die Kenntnis immunogener Tumorantigene, die von tumorreaktiven T-Zellen erkannt werden. In der vorliegenden Arbeit wurden tumorreaktive CD8+ zytotoxische T-Lymphozyten (CTL, cytotoxic T-lymphocytes) aus dem Blut eines HLA (human leukocyte antigen)-kompatiblen Fremdspenders generiert. Methodisch wurden hierzu CD8-selektionierte periphere Blutlymphozyten repetitiv mit der klarzelligen Nierenzellkarzinomlinie MZ1851-RCC (RCC, renal cell carcinoma) in einer allogenen gemischten Lymphozyten-Tumorzell Kultur (MLTC, mixed lymphocyte tumor cell culture) stimuliert. Aus den Responderlymphozyten wurden mit Hilfe des Grenzverdünnungsverfahrens klonale zytotoxische T-Zellen generiert und expandiert. Die CTL-Klone wurden anschließend phänotypisch mittels Durchflußzytometrie sowie funktionell mittels HLA-Antikörper-Blockadeexperimenten und Kreuzreaktivitätstests detailliert charakterisiert. Dabei konnte gezeigt werden, daß aus dem Blut eines allogenen gesunden Spenders CD8+ T-Zellen isoliert werden können, welche Reaktivität gegen Nierenzellkarzinome (NZK) aufweisen und über verschiedene HLA-Klasse-I-Allele restringiert sind. Die von den einzelnen CTL-Klonen erkannten Zielstrukturen zeigten entweder ubiquitäre (z.B. HLA-Cw*0704-reaktiver CTL-Klon E77) oder eine tumorspezifische (z.B. HLA-B*0702-restringierter CTL-Klon A4) Gewebeexpression. Zur Identifizierung der natürlich prozessierten Peptidliganden wurden die HLA-B/C-Allele unter Verwendung des monoklonalen Antikörpers B123.2 aus einem zuvor hergestellten Detergenslysat der Nierenzellkarzinomlinie MZ1851-RCC immunchromatographisch aufgereinigt. Aus den so isolierten HLA-Peptid-Komplexen wurden die tumorassoziierten Peptidliganden nach Säureeluation und Filtration abgespalten und über eine „reverse phase“-HPLC (high performance liquid chromatography) fraktioniert. Die Überprüfung der einzelnen HPLC-Fraktionen auf Bioaktivität erfolgte mit den korrespondierenden CTL-Klonen in 51Cr-Zytotoxizitätstests. Dabei wurde eine HPLC-Fraktion identifiziert, die die lytische Funktion des HLA-B*0702-restringierten CTL-Klons A4 auslösen konnte. Die bioaktive HPLC-Fraktion wurde dazu durch eine zweite (second dimension) Kapillar-Flüssigkeitschromatographie (Cap-LC, capillar liquid chromatography) in Subfraktionen geringerer Komplexität aufgetrennt und die darin enthaltenen Peptidepitope durch das MALDI-TOF/TOF (matrix assisted laser desorption/ionization- time of flight/time of flight)-Analyseverfahren sequenziert. Innerhalb dieser HPLC-Fraktion wurden eine Vielzahl von HLA-B/C-assoziierten Peptidliganden erfolgreich sequenziert, was die Effektivität dieser Verfahrenstechnik zur Identifizierung natürlich prozessierter HLA-Klasse-I-bindender Peptide unter Beweis stellt. Leider war es mit dieser Methode bisher nicht möglich, das von CTL-Klon A4 detektierte Peptidepitop zu sequenzieren. Dies liegt möglicherweise in der unzureichenden Konzentration des Peptidepitops in der bioaktiven HPLC-Fraktion begründet. In Folgearbeiten soll nun mit erhöhter Probenmenge beziehungsweise verbesserter Analytik der erneute Versuch unternommen werden, das Zielantigen des CTL-Klons A4 zu identifizieren. Die Kenntnis von Antigenen, die tumorspezifisch exprimiert und von CD8+ CTL aus gesunden Spendern erkannt werden, eröffnet neue therapeutische Möglichkeiten, das spezifische Immunsystem des Stammzellspenders nach allogener Blutstammzelltransplantation gezielt zur Steigerung von Tumorabstoßungsreaktionen (z.B. durch Vakzinierung oder adoptivem T-Zelltransfer) zu nutzen.

Synthesis of carbolines and analogues via rhodhium-catalyzed [2+2+2] cycloaddition with alkynyl-ynamides : application to the total synthesis of alkaloids

The main research theme of this dissertation is the synthesis of g- and b-carbolines using a metal-catalyzed [2+2+2] cycloaddition strategy of tethered alkynyl-ynamides (diynes) with nitriles. g- and b-carbolines form the core of a large group of natural product and represent important targets for organic chemists. Many of these carbolines showed pharmacological effects ranging from anti-tumor to anxiolytic and anti-HIV activity. A model study with N-Ethynyl-N-tosyl-2-(2-phenylethynyl)aniline and methyl cyanoformate showed that rhodium-based catalysts promote efficiently the reaction. A further optimization showed that the regioselectivity of the reaction can be tuned by the choice of the solvent or by the catalytic system. Application to a larger scope of diynes showed that the regioselectivity strongly depends on the type of substitution of the alkynyl moieties, giving regioselectivities in the range g:b = 1/0 to g:b = 0/1. This [2+2+2] cycloaddition approach for the synthesis of the g- and b-carboline cores was successfully applied to the first total synthesis of Isoperlolyrine and the total synthesis of Perlolyrine. Extension of this strategy to heterocumulenes as cycloaddition partners allowed the synthesis of a g-carbolinone, a thiopyrano[3,4-b]indol-3-imine and thiopyranothiones.

Preventing vasospasm improves outcome after aneurysmal subarachnoid hemorrhage: rationale and design of CONSCIOUS-2 and CONSCIOUS-3 trials

Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) is a frequent but unpredictable complication associated with poor outcome. Current vasospasm therapies are suboptimal; new therapies are needed. Clazosentan, an endothelin receptor antagonist, has shown promise in phase 2 studies, and two randomized, double-blind, placebo-controlled phase 3 trials (CONSCIOUS-2 and CONSCIOUS-3) are underway to further investigate its impact on vasospasm-related outcome after aSAH. Here, we describe the design of these studies, which was challenging with respect to defining endpoints and standardizing endpoint interpretation and patient care. Main inclusion criteria are: age 18-75 years; SAH due to ruptured saccular aneurysm secured by surgical clipping (CONSCIOUS-2) or endovascular coiling (CONSCIOUS-3); substantial subarachnoid clot; and World Federation of Neurosurgical Societies grades I-IV prior to aneurysm-securing procedure. In CONSCIOUS-2, patients are randomized 2:1 to clazosentan (5 mg/h) or placebo. In CONSCIOUS-3, patients are randomized 1:1:1 to clazosentan 5, 15 mg/h, or placebo. Treatment is initiated within 56 h of aSAH and continued until 14 days after aSAH. Primary endpoint is a composite of mortality and vasospasm-related morbidity within 6 weeks of aSAH (all-cause mortality, vasospasm-related new cerebral infarction, vasospasm-related delayed ischemic neurological deficit, neurological signs or symptoms in the presence of angiographic vasospasm leading to rescue therapy initiation). Main secondary endpoint is extended Glasgow Outcome Scale at week 12. A critical events committee assesses all data centrally to ensure consistency in interpretation, and patient management guidelines are used to standardize care. Results are expected at the end of 2010 and 2011 for CONSCIOUS-2 and CONSCIOUS-3, respectively.

Sustained impact of electronic alerts on rate of prophylaxis against venous thromboembolism

Advanced electronic alerts (eAlerts) and computerised physician order entry (CPOE) increase adequate thromboprophylaxis orders among hospitalised medical patients. It remains unclear whether eAlerts maintain their efficacy over time, after withdrawal of continuing medical education (CME) on eAlerts and on thromboprophylaxis indications from the study staff. We analysed 5,317 hospital cases from the University Hospital Zurich during 2006-2009: 1,854 cases from a medical ward with eAlerts (interventiongroup) and 3,463 cases from a surgical ward without eAlerts (controlgroup). In the intervention group, an eAlert with hospital-specific venous thromboembolism (VTE) prevention guidelines was issued in the electronic patient chart 6 hours after admission if no pharmacological or mechanical thromboprophylaxis had been ordered. Data were analysed for three phases: pre-implementation (phase 1), eAlert implementation with CME (phase 2), and post-implementation without CME (phase3). The rates of thromboprophylaxis in the intervention group were 43.4% in phase 1 and 66.7% in phase 2 (p<0.001), and increased further to 73.6% in phase3 (p=0.011). Early thromboprophylaxis orders within 12 hours after admission were more often placed in phase 2 and 3 as compared to phase 1 (67.1% vs. 52.1%, p<0.001). In the surgical control group, the thromboprophylaxis rates in the three phases were 88.6%, 90.7%, 90.6% (p=0.16). Advanced eAlerts may provide sustained efficacy over time, with stable rates of thromboprophylaxis orders among hospitalised medical patients.

Partnership Actions for Mitigating Syndromes (PAMS): Experience with a transdisciplinary tool in the NCCR North-South programme

Partnership Actions for Mitigating Syndromes (PAMS) are small transdisciplinary projects which bring scientific research insights from the NCCR North-South into policy and practice. They are implemented by researchers from different disciplines in collaboration with non-scientific actors. PAMS aim to implement and test approaches, methods and tools developed in research, in order to identify promising strategies and potentials for sustainable development. In this sense, they are solution-oriented. This paper will provide insights into our experience with PAMS, with a special focus on the implementation of transdisciplinarity and its outcomes. From 2001 to 2010, 77 PAMS were implemented in Africa, Asia and Latin America. An internal evaluation of the first 55 projects was conducted in 2006. Results of this evaluation led to a refinement and improvement of the tool. A second internal evaluation is currently underway in the NCCR North-South. This evaluation will provide an overview of 22 new PAMS. We will look at partners involved, project beneficiaries, activities implemented, outcomes achieved, and lessons learnt. In the first evaluation, transdisciplinarity was considered as “a form of collaboration within scientific fields … and as a form of continuous dialogue between research and society” (Messerli et al., 2007). The evaluation report concluded that this understanding of transdisciplinarity was not satisfactorily applied in the 55 projects. Only about half of the PAMS addressed mutual exchange between researchers and society. Some involved only one specific field of research and clearly lacked interdisciplinary co-operation, and most often knowledge was transferred mainly unilaterally from the scientific community to society, without society having any effect on science. It was therefore recommended to address transdisciplinarity more carefully in Phase 2 PAMS. The second evaluation, which is currently under way, is analysing whether and how this recommendation has been met, based on criteria defined in the NCCR North-South’s Outcome Monitoring Strategy. The analysis is focusing on partners with whom researchers interact and investigating whether practices have changed both in research and society. We are also exploring the role of researchers in PAMS. Preliminary results show that researchers can assume different roles, from direct implementation, mediation, and promotion of social learning between different actors, to giving advice as neutral outsiders.

Pirfenidone in patients with idiopathic pulmonary fibrosis (CAPACITY): two randomised trials

Background Idiopathic pulmonary fibrosis is a progressive and fatal lung disease with inevitable loss of lung function. The CAPACITY programme (studies 004 and 006) was designed to confirm the results of a phase 2 study that suggested that pirfenidone, a novel antifibrotic and anti-inflammatory drug, reduces deterioration in lung function in patients with idiopathic pulmonary fibrosis. Methods In two concurrent trials (004 and 006), patients (aged 40–80 years) with idiopathic pulmonary fibrosis were randomly assigned to oral pirfenidone or placebo for a minimum of 72 weeks in 110 centres in Australia, Europe, and North America. In study 004, patients were assigned in a 2:1:2 ratio to pirfenidone 2403 mg/day, pirfenidone 1197 mg/day, or placebo; in study 006, patients were assigned in a 1:1 ratio to pirfenidone 2403 mg/day or placebo. The randomisation code (permuted block design) was computer generated and stratified by region. All study personnel were masked to treatment group assignment until after final database lock. Treatments were administered orally, 801 mg or 399 mg three times a day. The primary endpoint was change in percentage predicted forced vital capacity (FVC) at week 72. Analysis was by intention to treat. The studies are registered with ClinicalTrials.gov, numbers NCT00287729 and NCT00287716. Findings In study 004, 174 of 435 patients were assigned to pirfenidone 2403 mg/day, 87 to pirfenidone 1197 mg/day, and 174 to placebo. In study 006, 171 of 344 patients were assigned to pirfenidone 2403 mg/day, and 173 to placebo. All patients in both studies were analysed. In study 004, pirfenidone reduced decline in FVC (p=0·001). Mean FVC change at week 72 was −8·0% (SD 16·5) in the pirfenidone 2403 mg/day group and −12·4% (18·5) in the placebo group (difference 4·4%, 95% CI 0·7 to 9·1); 35 (20%) of 174 versus 60 (35%) of 174 patients, respectively, had a decline of at least 10%. A significant treatment effect was noted at all timepoints from week 24 and in an analysis over all study timepoints (p=0·0007). Mean change in percentage FVC in the pirfenidone 1197 mg/day group was intermediate to that in the pirfenidone 2403 mg/day and placebo groups. In study 006, the difference between groups in FVC change at week 72 was not significant (p=0·501). Mean change in FVC at week 72 was −9·0% (SD 19·6) in the pirfenidone group and −9·6% (19·1) in the placebo group, and the difference between groups in predicted FVC change at week 72 was not significant (0·6%, −3·5 to 4·7); however, a consistent pirfenidone effect was apparent until week 48 (p=0·005) and in an analysis of all study timepoints (p=0·007). Patients in the pirfenidone 2403 mg/day group had higher incidences of nausea (125 [36%] of 345 vs 60 [17%] of 347), dyspepsia (66 [19%] vs 26 [7%]), vomiting (47 [14%] vs 15 [4%]), anorexia (37 [11%] vs 13 [4%]), photosensitivity (42 [12%] vs 6 [2%]), rash (111 [32%] vs 40 [12%]), and dizziness (63 [18%] vs 35 [10%]) than did those in the placebo group. Fewer overall deaths (19 [6%] vs 29 [8%]) and fewer deaths related to idiopathic pulmonary fibrosis (12 [3%] vs 25 [7%]) occurred in the pirfenidone 2403 mg/day groups than in the placebo groups. Interpretation The data show pirfenidone has a favourable benefit risk profile and represents an appropriate treatment option for patients with idiopathic pulmonary fibrosis.